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You didn’t miss it. From a technical perspective, it’s not an ideal manuscript. I think the best argument for margin reduction is actually the cine imaging. But what minimum voice tolerance did they accept? I don’t know.
I think our disagreement is nuanced. I do a lot of SBRT with and without MR guidance and cine imaging. My non MR is on a true beam with 6DOF. There is minimal doubt in my mind that the confidence in covering your target to X% with smaller margins is better with an MRL. However, I’m simultaneously arguing for isotoxic planning for potentially curative cases. In doing so, I’m throwing out the assumption that 95% PTV coverage matters (at least in some cases). I have to concede that no one has shown there is any harm to treating with 3 mm margins on a TrueBeam. Especially if doing something to ensure GTV coverage. If we believe there is a real toxicity benefit to margin reduction, it’s probably worth looking at closer with conventional technology rather than just assuming there are too many limitations.
What if you could have some sort of transpoder in the fiducials, maybe like a GPS of some sort? That way you could track in real time. Someone should invent this.
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Maybe Medicare would pay extra for it too 💡
Where I trained had Calypso and gave up on it. Your well timed sarcasm tells me we don’t need to discuss this (or CK) further.
2026 changed the game...
I do find it ironic that everyone says adaptive is a money grab but then the guy who doesn’t work in the US seems to be a big proponent
In the US, there has been a proliferation of ethos machines. Leadership has been very clear as to why. And it isn’t to treat all the cervix, bladder, pancreas, and weird abdomen/pelvis re-irradiation volume which we (don’t) have.
Like all those proton centers treating chordomas and kids
I admit that I also consider adaptive RT a money grab.
didn't they say they never actually adapted plans on mirage?
i had a call with XXXX Payor CMO yesterday. A radonc is submitting 30+ 77301 for adaptive with Ethos.
we approved it accidentally and payor not happy. but, there are no formal policies in place
i had a call with XXXX Payor CMO yesterday. A radonc is submitting 30+ 77301 for adaptive with Ethos.
we approved it accidentally and payor not happy. but, there are no formal policies in place
Presumably because of cost but they didn't even mention adapting (or not) in the methods or explicitly justify the choice. They just threw this in toward the end of the discussion: "Because adaptive radiotherapy was not performed in this study, the estimated cost differential for the MRI-guided workflow was approximately $1500."
"Show me the adaptive!"
-Rod Tidwell
"Approved it accidently." Sounds like a "happy accident" Bob Ross painting, especially for the radonc. "Look at those beautiful trees... there's money growing on them."
Have I said "no payor unit mechanism re: 77301" here many times? Some are saying it!
Fraction shaming has nothing on plan shaming if we want to talk about saving the system money
Name and shame.
Much worse than giving a breast cancer 33 fx or a prostate cancer 44 fx
How much worser*? Well since 77407 is about $450, and 77301 is about $1800, 30 adaptive IMRTs is about 3.4 times worser than 44 regular IMRTs.
Ergo adaptive is the worsest*.
*real English words
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As usual, our field conflates "slight improvement in OAR sparing" with "50% improvement in overall survival" via Tweet
This is a slippery slope.
Do we really want to celebrate payers not paying rad oncs?
How about we call out the ridiculousness in our field so the rest of us don't suffer from payment cuts?
ASTRO and Co went medieval on urorads a decade+ ago for far less financially toxic practices
Prior auth is 98-99% 💩 but it's a few bad actors that IMO make it a necessary evil. No one needs 33fx in early stage breast, the data is worse etc
Yeah I hear all that. I’m just saying that this is a new indication for rad onc billing whether or not we all have access to it now (I do not). It’s not academic vs non academic IMO.
I guess it depends on what kind of case it is but there may be a future where we are all able to easily do this and idk being happy about cuts is a self defeating exercise
You mention Urorads (non sequitur a bit) but since you mention it - that’s a good example of cutting your nose to spite your face as is this potentially
In general, I agree. We shouldn't. And that's why I don't really have a judgment on it other than we need to define a policy.
What I've noted in my 4-5 years of doing this is exactly what Alligator says and exactly why all regulations exist - 5% of people cause 90% of the problem.
I cannot tell you how many insane things I have to review. I'm not talking conventional fx for prostate. I'm seeing protons for LG DCIS in 70 yo woman. 60 Gy in 60 Fx BID for early stage breast cancer / skin cancer. Daily IGRT for 30 fx of SRT for skin cancer. 60/30 for elderly lady with low risk omission allowable stage I breast cancer. Etc.
I do understand most of you don't deal with the company I work for. I suspect we don't save as much as other companies, but nobody really complains about us either. And the complaints matter. I.e. - we just scored a HUUUUUUGE statewide contract b/c the current PA company has led to such anger. And, I think my state will be better off for it with us reviewing rather than the other company.
15 years ago, plenty of prominent rad oncs argued that IMRT was also a money grab. Made sure to tell us why 3D was just as good for curative cases along with reasons IMRT would be more toxic and have higher failure rates. Those arguments didn’t age well.
yep.
If I bill a 77407 and 77301 daily, I can almost make as much money as the academic center across the street who just bills 77407 daily
FletchersGarb
Full Member
One way payors will deal with it is that 77301 will become a code that requires prior authorization. Policies will be posted. I'm surprised 77280 was never a PA code given all DermRads abuse.
I can only speak for myself, but I (and many others) gave it the college try. Genuinely feel that organized Rad Onc is too far gone and Im fully out at this point. I do not think things will get better as long as rad onc remains a dominant revenue source for hospitals and profitable for freestanding owners. It could get a lot worse with our addiction to massively expensive and unnecessary capital.
The only way things can change is if leadership holds itself accountable or members exit the societies en masse. The field is tiny and loaded with leaders that are dishonest and vindictive, so I just dont see either of those happening.
I have to laugh at this a little bit guys.
Let’s say you sim a patient and you get down to 2 different plans, with one being superior than the other. You obviously choose the better plan.
Let’s say you shoot a cone-beam on treatment and the adaptive plan you come up with is superior than the one you originally planned.
So now all of a sudden, it’s bad to pick the better plan?
We all sound like our grandparents who hate anything new that comes out.
Let’s say you sim a patient and you get down to 2 different plans, with one being superior than the other. You obviously choose the better plan.
Let’s say you shoot a cone-beam on treatment and the adaptive plan you come up with is superior than the one you originally planned.
So now all of a sudden, it’s bad to pick the better plan?
We all sound like our grandparents who hate anything new that comes out.
Sorry but f—- the payers. They are pure slime. Did you see how Evicore miraculously (and I’m sure by pure coincidence) took out all of the language supporting SGRT as soon as the new coding came out?
I hear you - I agree. We didn’t do that. “Prior auth” didn’t do that. Evicore did.
Adaptive can be clinically useful
Adaptive can be overused/abused for financial gain
Both can be true
FletchersGarb
Full Member
A potential Evicore policy in adaptive RT could be something like this. IMRT planning charges (77301) are approved x 1 for any IMRT. Approved up to 7 units for H&N, cervix, locally advanced lung, etc, if medical necessity is documented (anatomical change, department may have to submit images proving on-treatment tumor change).
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It's disgusting honestly. The self righteous virtue signaling and mental 'sturb on ebm and knowing studies and then to see wasteful evidence-free spending when it comes to particles and adaptive
Isn’t it rather remarkable that Medicare has never established fraction or units limits on any rad onc code
44 fractions IMRT for a ISUP 1 localized prostate caccer were/are a money grab.
Im talking about IMRT globally for thinks like curative lung and upper GI tumors.
You can bet they’re working on a policy that is a thousand times more restrictive than this. Give them an inch and they’ll take a country mile every single time. We saw that with APM and numerous times before that in every single specialty.
Why would you limit it to certain disease sites? An anatomic change in a pelvic malignancy outside of cervix is not worth adapting? How did you come up with 7?
Sorry, but these kinds of blanket policies are silly and are simply insurance companies not wanting to pay us - this has always been their goal, but we don’t have to do their work for them.
We can fight it as much as we want, but adaptive is the future. It makes no sense NOT to make a plan that fits the patient’s anatomy right before they’re treated - in ANY disease site at ANY time.
Imagine asking a patient if they think it’s OK to adjust their plan based on their anatomy that day. They probably assume that’s what’s already happening. Imagine asking a patient if they think it’s OK for their insurance company to limit their doctor’s ability to do that. Imagine asking a patient if they think it makes sense for their doctor to advocate for insurance policies not to allow them to do that….?
Nah. And really it was 45. That was the MSKCC standard for all prostate circa 2005 (to when? 2015?) eg and was considered “The Cadillac” IMRT regimen by many. And NCCN had up to 45 as acceptable for all prostate risk levels up until a few years ago. If you look up old ACR appropriate use criteria I bet it lists 45 as acceptable or good for all levels.
In my opinion the culture on this changed more than the science did.
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I do think adaptive workflows will become way more efficient eventually such that we can quickly do it for most disease sites. Currently, does it make sense to adapt a 28 fraction routine prostate on ethos 2.0 considering it can be an extra 45 mins of table time, extra physician time, prostate/bladder/rectum move so anyway will need an uncertainty margin, unclear if changes outcomes, etc? But if we could do it without any/much added penalty in the future…sure why not.
Efficient adaptive is the future, unclear how much this will improve outcomes, will depend on disease site and patient anatomy. I’d support this statement.
Reimbursement for adaptive is a whole separate can of worms.
An extra 45 minutes for a localized prostate cancer case on a Ethos per fraction are too long.
We usually do these in 15-20 minutes. So, it's perhaps 5 minutes longer than a standard non-adaptive-IGRT ?
Prostate + lymphatics with a SIB on a lymph node usually takes about 25 minutes, cervix can go up to 30 minutes.
Agree it is the future
Hospital billed case of 5 fx adapted (5x) sbrt prostate charges are $300k+ for commercial payor
If collecting typical 25%, that’s $75k. 44fx IMRT is even more.
I’m not going to be the person to make value judgment about this, but just consider if this type of thing becomes an outlier - you know Medicare funding is zero sum. If our pie gets even bigger even though it’s tiny, we are the red headed stepchild.
If I were to spend political capital on anything it would be to increase and stabilize tx delivery charges and make sure that we are not having 15-20% revenue loss.
There are 40 centers or so doing this. But most of are not. IMO, this is like all of us banding together to support protons. Sure it may be overall good for proton centers, but the rest of us may pay the price.
Hospital billed case of 5 fx adapted (5x) sbrt prostate charges are $300k+ for commercial payor
If collecting typical 25%, that’s $75k. 44fx IMRT is even more.
I’m not going to be the person to make value judgment about this, but just consider if this type of thing becomes an outlier - you know Medicare funding is zero sum. If our pie gets even bigger even though it’s tiny, we are the red headed stepchild.
If I were to spend political capital on anything it would be to increase and stabilize tx delivery charges and make sure that we are not having 15-20% revenue loss.
There are 40 centers or so doing this. But most of are not. IMO, this is like all of us banding together to support protons. Sure it may be overall good for proton centers, but the rest of us may pay the price.
In the area of ever constrained reimbursement, billing will find a way. Many of us like to sit here in front of our devices, all smug and point and laugh at things like adaptive planning, rectal spacers, etc.
But ironically, some of the same people complain loudest about ever shrinking reimbursement.
Adapt or suffer.
But ironically, some of the same people complain loudest about ever shrinking reimbursement.
Adapt or suffer.
But, Grandmaster Funk -
Say we had the same reimbursement for delivery as we did in 2013. We would all probably be happy-ish right now (although many of us are perpetually unhappy about the course of things).
Instead, we have what we have, and we have to find ways to make up income loss.
And perhaps this is the way to do it. However, when code review time comes, all of a sudden 77301 / 77338 / 77336 etc are going to skyrocket like 77014 did for IGRT. And it got deleted.
Adaptive is the future. 100% agree. Do you believe the initial contouring and planning cognitive and manual labor is equivalent to what you do on the machine when you adapt? I have never done a case. But, if it took me the same time to do a pancreas ablation or head neck re-contour and the same amount of thinking and iteration with the planner / planning software, we are talking hour + per case.
I have no experience with this. So, if you are saying that it takes the same amount of time and resources to do, then perhaps I can understand why the same code can be used 30-40 times in a course of prostate IMRT.
Say we had the same reimbursement for delivery as we did in 2013. We would all probably be happy-ish right now (although many of us are perpetually unhappy about the course of things).
Instead, we have what we have, and we have to find ways to make up income loss.
And perhaps this is the way to do it. However, when code review time comes, all of a sudden 77301 / 77338 / 77336 etc are going to skyrocket like 77014 did for IGRT. And it got deleted.
Adaptive is the future. 100% agree. Do you believe the initial contouring and planning cognitive and manual labor is equivalent to what you do on the machine when you adapt? I have never done a case. But, if it took me the same time to do a pancreas ablation or head neck re-contour and the same amount of thinking and iteration with the planner / planning software, we are talking hour + per case.
I have no experience with this. So, if you are saying that it takes the same amount of time and resources to do, then perhaps I can understand why the same code can be used 30-40 times in a course of prostate IMRT.
You raise some valid points. I am not making value judgements on what people do. I have personally done adaptive treatments but of the old, traditional variety - typically with locally advanced H&N cancer. New CT sim, new thermoplastic mask, new contours, dose summation, etc. - all done offline. Even with this approach it is fairly straightforward due to the strength of auto-segmentation, even to GTV/CTV and lymph node groups.
Will CMS delete the code if people abuse it? Probably, but CMS will do CMS things.
Absolutely agree that from a resource/time-commitment standpoint, the 45 min adaptive slots which are frankly faster than I’m seeing at most places is not financially advantageous since you can treat 3-4 patients in that same slot. And that’s before you count the incredible increase in price on the machine and the service contracts.
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So unfair, but I’m preaching to the choir of course. Rad onc could double its Part B cost and it would be 3% or less of total Medicare Part B spend. I think CMS looks and thinks “Well gee much less than 3% of doctors are rad oncs!”
AUA of 22, 85cc gland and an underlying hx of UC? Nah
Unlike early breast, still a role for conventional fx in PCa
We cost less than the spending on keytruda alone
Does anyone that impacts policy actually think like this?
Immunotherapy has done a lot for patients. Everyone knows our drug spending is out of control. What exactly is the argument here? Radiation should get more money to spend on technology with unclear benefit because we spend too much money on drugs? I dont get it, and this has been the main talking point for years now.
As we've seen, this does not land with the government the way ASTRO thinks it does...
Totally! I’d be terrible at this
It’s time related. This is why the original cuts happened in early 2010s. Astro had a brochure that said IMRT tx was 15 min and then they were getting pain for 45 min. CMS showed them their own brochure and chop chop!
